Martin Lhuaire

Vascular complications following liver transplantation: A literature review of advances in 2015

Although vascular complications (VCs) following orthotopic liver transplantation (OLT) seldom occur, they are the most feared complications with a high incidence of both graft loss and mortality, as they compromise the blood flow of the transplant (either inflow or outflow). Diagnosis and therapeutic management of VCs constitute a major challenge in terms of increasing the success rate of liver transplantation. While surgical treatment used to be considered the first choice for management, advances in endovascular intervention have increased to make this a viable therapeutic option. Considering VC as a rare but a major and dreadful issue in OLT history, and in view of the continuing and rapid progress in recent years, an update on these uncommon conditions seemed necessary. In this sense, this review comprehensively discusses the important features (epidemiological, clinical, paraclinical, prognostic and therapeutic) of VCs following OLT.

A Rare Cause of Chronic Abdominal Pain: Recurrent Sub-torsions of an Accessory Spleen

Accessory spleen is defined as one, two, or three nodules of additional ectopic splenic parenchyma hung by a vascular pedicle generally near the spleen. Despite a relatively high frequency (from 10 to 30 % of the population based on autopsy studies), most accessory spleens are asymptomatic. Although cases of accessory spleen were clearly described in the literature, this perplexing diagnosis is often delayed and rarely made preoperatively. We repot episodic recurrences of abdominal pain in a 66-year-old man attributed to iterative sub-torsions of an accessory spleen, as well as a comprehensive review of the literature.

Laparoscopic Pringle maneuver: how we do it?

Laparoscopic liver resection (LLR) is technically possible with new devices which allow a relatively bloodless liver parenchymal transection. Despite, the main concern remains intraoperative hemorrhage. Currently, perioperative excessive blood loss during LLR is difficult to control with necessity of laparotomy conversion. Moreover, major blood loss requires transfusion and increases postoperative morbidity and mortality. When in-flow is limited by the hepatic pedicle clamping, it reduces intraoperative blood loss. The Pringle maneuver, first described in 1908, is the simplest method of inflow occlusion and currently can be achieved during LLR. The purpose of this note was to describe two different modalities of Pringle maneuver used by two different teams during LLR.

Liver hilar abscesses secondary to gastrointestinal perforation by ingested fish bones: surgical management of two cases

Several hepatobiliary complications secondary to gastrointestinal perforation after ingestion of a fish bone have been described in the literature, the most common being liver abscess, which can be potentially fatal. Treatment involves removal of the foreign body if possible (endoscopically or surgically), drainage of the abscess (radiologically or surgically), and appropriate antibiotic therapy. To our knowledge, no cases of hepatic hilar abscesses secondary to gastrointestinal perforation by a fish bone have been described in the literature. We report surgical management of two cases of abscess localized in the hepatic hilum secondary to the ingestion of fish bones.

Chest drain in the liver

A 44-year-old man was admitted in intensive care unit after a suicide attempt by ingestion of 300 mL of caustic (WC net ouragan). During hospitalization, the patient was presenting acute right chest pain with a 39.6°C fever, tachycardia and hypoxaemia after hyperemesis. A thoracic computed tomographic scan (CT) with injection showed a right inhalation pneumopathy and a wide right pleural effusion (Fig. 1A) requiring a pleural drainage. The chest drain (Mallinckrodt drain trocard) was placed basally in the eighth intercostal space, but unexpectedly produced 340 mL of veinous blood. The patient was hemodynamically stable. An emergency thoracic-abdominal CT scan with injection showed an unsuitable setting of the chest drain which was passing through the liver (Fig. 1B and C) and no active bleeding or major vessels damage was seen. The drain was successfully removed without early complications and the controlled CT realized 1 h after the ablation showed the tract of the drain without active bleeding (Fig. 1D). There were no subsequent complications as the controlled CT showed it 1 week after. Only two reports in the literature describe the removal of a chest drain from the liver using coils for tract embolization about the exact extent of underlying vascular damage (1, 2). In this case, the chest drain was removed without embolization because it ended blindly.

Developmental anatomy of the liver from computerized three-dimensional reconstructions of four human embryos (from Carnegie stage 14 to 23).

BACKGROUND & AIM Some aspects of human embryogenesis and organogenesis remain unclear, especially concerning the development of the liver and its vasculature. The purpose of this study was to investigate, from a descriptive standpoint, the evolutionary morphogenesis of the human liver and its vasculature by computerized three-dimensional reconstructions of human embryos. MATERIAL & METHODS Serial histological sections of four human embryos at successive stages of development belonging to three prestigious French historical collections were digitized and reconstructed in 3D using software commonly used in medical radiology. Manual segmentation of the hepatic anatomical regions of interest was performed section by section. RESULTS In this study, human liver organogenesis was examined at Carnegie stages 14, 18, 21 and 23. Using a descriptive and an analytical method, we showed that these stages correspond to the implementation of the large hepatic vascular patterns (the portal system, the hepatic artery and the hepatic venous system) and the biliary system. CONCLUSION To our knowledge, our work is the first descriptive morphological study using 3D computerized reconstructions from serial histological sections of the embryonic development of the human liver between Carnegie stages 14 and 23.

Human developmental anatomy: Microscopic magnetic resonance imaging (μMRI) of four human embryos (from Carnegie Stage 10 to 20)

BACKGROUND AND AIM Technological advances in the field of biological imaging now allow multi-modal studies of human embryo anatomy. The aim of this study was to assess the high magnetic field μMRI feasibility in the study of small human embryos (less than 21mm crown-rump) as a new tool for the study of human descriptive embryology and to determine better sequence characteristics to obtain higher spatial resolution and higher signal/noise ratio. METHODS Morphological study of four human embryos belonging to the historical collection of the Department of Anatomy in the Faculty of Medicine of Reims was undertaken by μMRI. These embryos had, successively, crown-rump lengths of 3mm (Carnegie Stage, CS 10), 12mm (CS 16), 17mm (CS 18) and 21mm (CS 20). Acquisition of images was performed using a vertical nuclear magnetic resonance spectrometer, a Bruker Avance III, 500MHz, 11.7T equipped for imaging. RESULTS All images were acquired using 2D (transverse, sagittal and coronal) and 3D sequences, either T1-weighted or T2-weighted. Spatial resolution between 24 and 70μm/pixel allowed clear visualization of all anatomical structures of the embryos. CONCLUSION The study of human embryos μMRI has already been reported in the literature and a few atlases exist for educational purposes. However, to our knowledge, descriptive or morphological studies of human developmental anatomy based on data collected these few μMRI studies of human embryos are rare. This morphological noninvasive imaging method coupled with other techniques already reported seems to offer new perspectives to descriptive studies of human embryology.

Post-hepatectomy liver failure: Should we consider venous outflow?

Highlights • Post hepatectomy liver failure (PHLF) is similar to the ‘small-for-size’ syndrome (SFSS) in liver transplantation (LT).• We report a case of PHLF involving clinical presentation of posthepatectomy-related SFSS secondary to obstructed venous outflow in the liver remnant, following extended right hepatectomy.• Although inflow hypertension is clearly implicated in the pathogenesis of SFSS some authors have suggested that outflow obstruction is a potential pathogenic factor.• The present case support the hypothesis that outflow obstruction could lead symptoms similar to SFSS.